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® Quadriceps Therapy System ® Incorporating the Kneehab XP in to Your Patellofemoral Joint Pain Treatment Program Kneehab is useful for addressing both early muscular activation deficits and later power and strength development concerns with a patellofemoral joint (PFJ) rehabilitation progression. The following program suggests ways to combine the Kneehab with a progression of exercises to address quadriceps muscle dysfunction/weakness and patellofemoral pain. The treatments described in this brochure may be provided with Kneehab XP Controller Type 412 and Kneehab XP Conductive Garment Type 421. CLINICAL SCENARIO: Acute, Post-Surgical Duration Weeks 1-6, post-surgery Recommended Kneehab Programs Program 3 or 4 per patient comfort* Program 3: 20 minutes (10 sec on: 20 sec off cycle) Program 4: 20 minutes (10 sec on: 30 sec off cycle) Clinical goals Manage pain Reduce swelling Muscle facilitation Restore range of motion Workout Structure Weeks 1-3: Volitional contraction exercises done independently of Kneehab; Kneehab applied 2x daily at sub-maximal contraction intensity levels. Patient is in supine position or sitting with legs in a supported extended position during application of Kneehab during this stage. Weeks 3-6: Kneehab set to full contraction intensity. Volitional exercise contractions performed in tandem with Kneehab sessions. Isometric contraction may be performed in full knee extension or at a fixed angle between 45-90° of knee flexion (per comfort and surgical precautions) Week 6: Advance to strengthening phase Workout Frequency 2 times/daily Workout Duration 6 weeks* Progressions Per comfort with existing level, attainment of clinical goals Clinical Measures Effusion, adequate quadriceps isometric contraction, straight leg raise with no extensor lag Precautions Pain, effusion, PFJ surgical procedure precautions, increased lateral patellar translation observed Do not cinch the Kneehab around the quadriceps. Full contact with conductive surface is sufficient to ensure Multipath stimulation is optimally delivered. Avoid direct contact with incision or broken skin. Other Considerations Discontinue protocol if patient exhibits unresolving pain or effusion; post-operative restrictions. Avoid Open Kinetic Chain exercises through 30-0° arc of motion. * Workout duration may vary per patient/condition CLINICAL SCENARIO: Quadriceps strengthening following quadriceps muscle dysfunction or weakness, Patellofemoral pain Duration 8 - 12 Weeks Recommended Kneehab Programs Program 1 or 2 per patient comfort* Program 1: 20 minutes (5 sec on: 10 sec off cycle) Program 2: 20 minutes (10 sec on: 10 sec off cycle) Clinical goals Restore quadriceps strength Retard disuse atrophy Combat loss of additional muscle volume Workout Structure Select 3 – 5 exercises from protocol per patient comfort and competence Cycle through selected exercise from protocol, in tandem with Kneehab program. Complete exercise rotations as follows: If 3 exercises selected: 2 minutes per exercise x 3 cycles (18 minute regimen) If 4 exercises selected: 2.5 minutes per exercise x 2 cycles (20 minute regimen) If 5 exercises selected: 2 minutes per exercise x 2 cycles (20 minute regimen) Workout Frequency 3 times/week (per knee symptoms and muscle soreness) Workout Duration 8 - 12 weeks* Progressions Per mastery and comfort with existing level Clinical Measures Reported pain with stairs, circumferential thigh girth, maximum single limb squat depth and/ or hop distance Precautions Pain, effusion, poor technique/alignment control, PFJ surgical procedure precautions, increased lateral patellar translation observed Other Considerations Discontinue protocol if patient exhibits unresolving pain or effusion; post-operative restrictions. Avoid Open Kinetic Chain exercises through 30-0° arc of motion. * Workout duration may vary per patient/condition Incorporating Kneehab for quadriceps strengthening + The patient performs a volitional quadriceps contraction in tandem with the stimulated contraction from the Kneehab. + Kneehab is set at an intensity that elicits a good contraction but does not provoke patellofemoral symptoms. + Volitional contractions are performed during each exercise as the patient cycles through their exercise array. Therapeutic Exercises Exercises vary by angle of knee flexion and weight-bearing status for maximal patellofemoral joint comfort and maximal functional carry-over of the program. KNEEHAB QUADRICEPS STRENGTHENING EXERCISE PROGRESSION LEVEL 1 Open Kinetic Chain Extension (A) Open Kinetic Chain Flexion (B) Closed Kinetic Chain Extension (C) Closed Kinetic Chain Flexion: Squat (D) Closed Kinetic Chain Flexion: Step (E) Isometric contraction at 0° knee flexion with Kneehab ”on” cycle; relax during “off” cycle Isometric contraction, bilateral stance Isometric press (against belt) at fixed knee flexion angle Shallow squat hold ()50°) Press up into squat hold from high stool/counter with Kneehab “on” cycle, sit to rest with “off” Leg Press: Press & hold against weight in a shallow squat position with “on” cycle, relax during “off” cycle 2-4” step, anterior or lateral weight shift: Isometric shift & hold with “on” cycle, shift weight off limb during “off” cycle * Knee flexion angle (45-90°) per comfort * Shift direction per comfort LEVEL 2 Isometric contraction maintained + straight leg raise during Kneehab “on” cycle; relax with “off” cycle Concentric press through deep flexion (90° A45°) Concentric TKE w/ resistance band Progress amount of weight maintained over involved limb Concentric press up through shallow squat ()50°) (Using high stool / counter or leg press) Shift + step-up (Anterior or Lateral) Concentrically press up step with “on” cycle Step back down to start position with “off” cycle LEVEL 3 Add ankle weight for straight leg raise** (complete exercise same as previously) Increased resistance (concentric) or intensity of push (isometric) Isometric contraction in single limb stance at 0° knee flexion (return to 2 legs with “off” cycle) Deeper squat starting depth OR Add weight or band resistance to shallow squats** (IsometricAConcentric) Shift + hold at higher step OR Add weight or band resistance at same step height** (isometric or concentric exercise) * Selection per comfort * Selection per comfort LEVEL 4 * Selection per comfort Isometric contraction in single limb stance at fixed angle (10-30° knee flexion); return to 2 legs with “off” cycle Progress to 1 leg squat or leg press (Use opposite leg or hand support for gradual progression to 1 leg squat) Use clinical judgment when advancing patients to these exercises, i.e. symptoms ** Add weight or band resistance under the supervision of a clinician OPEN KINETIC CHAIN EXTENSION (A) Quadriceps Isometric Contraction – LEVEL 1 Straighten the leg completely (toes pointing up). Contract the quadriceps and hold the contraction for the duration of a single Kneehab contraction. Release and repeat. Quadriceps Isometric + Straight leg raise – LEVEL 2 Contract the quadriceps with the Kneehab contraction to lock the knee in full extension, then lift and lower the leg, maintaining full knee extension throughout the motion. Release and repeat. Quadriceps Isometric + Weighted straight leg raise – LEVEL 3 Perform the straight leg exercise as instructed prior, with the addition of ankle weight resistance. Start at a comfortable amount of weight and gradually progress per strength. OPEN KINETIC CHAIN FLEXION (B) Isometric Contraction – LEVEL 1 Secure a strap around the ankle to hold the knee at a fixed angle of flexion between 90° to 45° (per comfort). Press into the strap to create an isometric contraction and hold for the duration of the Kneehab contraction. Release and repeat. Concentric Contraction – LEVEL 2 Secure an elastic band around the ankle with the knee flexed to approximately 90°. As the Kneehab contraction comes on, press the knee into a slightly more extended position (no higher than 45°). Release and repeat. CLOSED KINETIC CHAIN EXTENSION (C) - Stance Progression Isometric Contraction (Bilateral Stance) – LEVEL 1 Contract the quadriceps while standing with your weight evenly distributed. Hold the contraction for the duration of a single Kneehab contraction. Release and repeat. Concentric Contraction (Bilateral Stance) – LEVEL 2 With an exercise band placed behind the knee, bend the knee to a 20° angle (a) and slowly straighten it while contracting the quadriceps (b). Perform in tandem with the Kneehab contraction. Release and repeat. Isometric Contraction (Single limb stance) – LEVEL 3** Shift weight onto one leg (keeping the knee straight) and contract the quadriceps in tandem with the Kneehab contraction (use balance support as needed) (a). Release and transition back to 2 legs, then repeat with the next contraction cycle (b). ** For safety, patients should perform single leg stance exercises with a chair or support surface close by in the event of loss of balance. Isometric Contraction (Single limb stance in slight flexion) – LEVEL 4** Shift weight onto one leg (with the knee in a slight bend) and contract the quadriceps in tandem with the Kneehab contraction (use balance support as needed). Release and transition back to 2 legs, then repeat with the next contraction cycle. ** For safety, patients should perform single leg stance exercises with a chair or support surface close by in the event of loss of balance. (a) (b) (a) (b) CLOSED KINETIC CHAIN: SQUAT (D) Squat Hold – LEVEL 1 Start in a seated position with both feet on the ground (a). When the Kneehab contraction initiates, slowly press up with both legs and hold a squat position at a comfortable angle of knee flexion (< 50°) (b). Maintain this shallow squat hold for the duration of the contraction. When the Kneehab contraction is completed, sit back down to rest. Repeat the squat holds with the contraction cycles. (a) (b) Concentric Squat Press-Up – LEVEL 2 Start in a seated position with both feet on the ground (a). When the Kneehab contraction initiates, slowly press up with both legs through the rising phase of the squat motion until arriving in full upright stance (b). When the Kneehab contraction releases, lower back down to a seated position to rest. Repeat the squat press-ups with each contraction. (a) (b) Intermediate Squat Progressions – LEVEL 3 Progress the 2-legged squat activity by either*: (a) Performing a hold or press-up from a deeper squat starting position (b) Adding weight or band resistance with the hold or the press-up activity * Choose the progression that is best tolerated per symptoms and control. Single-Leg Squat – LEVEL 4 Start in a seated position with 1 foot on the ground. When the Kneehab contraction initiates, press up with 1 leg and either: (a) (b) (a). Hold a single leg squat position for the duration of the Kneehab contraction (b). Press through the rising phase of the squat motion until arriving in full upright stance When the Kneehab contraction releases, lower back down to a seated position to rest (c). Repeat the squat holds or press-ups with each contraction. * Tip-toe support from the opposite limb or hand support may be used to help transition safely and comfortably into single leg squatting. (see photo) (c) Add external weight (dumbbell) to squatting position Progress to a deeper starting squat position CLOSED KINETIC CHAIN: STEP (E) Anterior weight shift onto step - LEVEL 1 Start with the involved leg up on a small step placed slightly to the front (a). When the Kneehab contraction initiates, slowly shift a comfortable amount of weight forward onto the step, leaning forward at the trunk and bending at the knee and hip (b). Hold this position for the duration of the contraction. Shift body weight back to the opposite limb (leaving the involved foot up on the step) to rest. Repeat the weight shift & hold with each contraction cycle. (a) (b) (a) (b) * Be watchful for proper body position * Increase amount of weight shifted and height of step as tolerated. * Monitor the amount of weight shifted with each repetition by using a bathroom scale securely placed on top of the step Lateral weight shift onto step - LEVEL 1 Start with the involved leg up on a small step placed slightly to the side (a). When the Kneehab contraction initiates, slowly shift a comfortable amount of weight over onto the step, sitting back slightly into the hip and bending at the knee slightly (b). Hold this position for the duration of the contraction. Shift body weight back to the opposite limb (leaving the involved foot up on the step) to rest. Repeat the weight shift & hold with each contraction cycle. * Be watchful for proper body position * Increase amount of weight shifted and height of step as tolerated (b). * Monitor the amount of weight shifted with each repetition by using a bathroom scale securely placed on top of the step Anterior step up – LEVEL 2 Start with the involved leg up on a small step placed slightly to the front (a). When the Kneehab contraction initiates, shift weight over onto the step and slowly press up the height of the step (b-c). When the Kneehab contraction releases, lower back down the step to the starting position. Repeat the step-ups with each contraction. (a) (b) (c) * Be watchful for proper body position * Gradually increase height of step or add band or dumbbell resistance to increase challenge, per symptoms and control Increase step height and external load (dumbbell) as tolerated Lateral step up – LEVEL 2 Start with the involved leg up on a small step placed slightly to the side (a). When the Kneehab contraction initiates, shift weight over onto the step and slowly press up the height of the step (b-c). When the Kneehab contraction releases, lower back down the step to the starting position. Repeat the step-ups with each contraction. * Be watchful for proper body position * Gradually increase height of step or add band or dumbbell resistance to increase challenge, per symptoms and control (a) (b) (c) CLOSED KINETIC CHAIN: STEP (E) CONTINUED Step Exercise Progressions – LEVEL 3 Progress the step exercise per symptoms and control in any of the following ways: 1. Use a higher step with either holds or step-ups 2. Use external load/resistance (dumbbell, resistance band) with either holds or press-up Useful clinical tools: 1. Bathroom scales can be useful for observing symmetrical weight bearing with the 2 legged squatting activities and observing the amount of weight shifted with the step & hold activities. (see photos) 2. If full body weight squatting or stepping is not tolerated due to pain or weakness, consider the following strategies: a. Have the patient use hand support at a sturdy counter or overhead bar to offload weight from the limb(s) b. Have the patient use a leg press machine at a comfortable knee flexion angle with a comfortable load (isometric or concentric presses) c. Have the patient perform a “home leg press” by lying supine on the floor and pressing into an exercise ball that is secured in a corner (see photo) Key points to consider with quadriceps muscle training for patellofemoral conditions Patellofemoral joint (PFJ) pain can be aggravated via joint stress, < 30° knee angle positions in non-weight bearing settings and deeper knee angle positions in weight-bearing settings. + Non-weight bearing exercises where the knee is flexed at a < 30° position should be avoided + Preferred knee angles for non-weight bearing exercises are 45° to 90° + Non-weight bearing strengthening exercises in deeper angles of knee flexion may be less stressful to the patellofemoral cartilage due to increased contact area + There is less lateral movement of the patella when the knee is flexed at a deeper angle. An exception to this is where there is a known cartilage defect within the joint. + Weight-bearing strengthening exercises create less PFJ stress at < 50° of knee flexion + Weight-bearing strengthening exercises, where the knee is flexed at a greater degree, increases PFJ stress and should only be initiated based on the patient’s individual progress and continued symptom control. Patellar Instability + Improved quadriceps muscle function may improve patellar stability + The patella demonstrates increased lateral movement through the arc of motion near full knee extension (30°-0°) in non-weight bearing situations. Exercise in such a manner should be avoided. + Non-weight bearing strengthening exercises utilizing deeper knee angles demonstrate reduced lateral movement of the patella. 45° to 90° of motion is considered a safe range for quadriceps strengthening. - An exception would be with a known cartilage defect or surgical precaution. + These deeper angle/non-weight bearing exercises are also less stressful to the patellofemoral cartilage, except when there is a known cartilage defect within the joint Kneehab Program Selection Kneehab XP delivers 9 programs total — 6 Multipath NMES programs and 3 TENS programs. Programs not specifically referenced in this brochure can be utilized in an individual program, e.g. Program 9 TENS for pain relief, as determined by the clinician. Program Program Description Frequency (Seconds) (Hz) 1 – Ramp Up 5 – Contraction Time 0.5 – Ramp Down 10 – Relaxation Time 50Hz 1 – Ramp Up 10 – Contraction Time 0.5 – Ramp Down 10 – Relaxation Time 50Hz 1 – Ramp Up 10 – Contraction Time 0.5 – Ramp Down 20 – Relaxation Time 50Hz 1 – Ramp Up 10 – Contraction Time 0.5 – Ramp Down 30 – Relaxation Time 50Hz 1 – Ramp Up 5 – Contraction Time 0.5 – Ramp Down 5 – Relaxation Time 35Hz (Multipath) 1 – Ramp Up 10 – Contraction Time 0.5 – Ramp Down 50 – Relaxation Time 70Hz P7 Continuous stimulation time 99Hz Continuous stimulation time 4Hz Continuous stimulation time 125Hz P1 (Multipath) P2 (Multipath) P3 (Multipath) P4 (Multipath) P5 (Multipath) P6 (TENS) P8 (TENS) P9 (TENS) Kneehab XP indications for use: + Early post-surgical quadriceps strengthening and improved post-surgical knee stability secondary to quadriceps strengthening + Muscle re-education of the quadriceps + Maintain or increase range of motion of the knee joint + Prevent or slow disuse atrophy in the quadriceps + Increase local blood circulation + Symptomatic relief and management of chronic, intractable pain + Management of intractable pain and relief of pain associated with arthritis + Adjunctive treatment in the management of acute, post-surgical or post-traumatic pain + Adjunctive therapy in reducing the level of pain and symptoms associated with osteoarthritis of the knee About us: 40 years of innovation and advanced patient care neurotech® is a division of Bio-Medical Research (BMR) Ltd., a worldwide leader providing innovative devices for pain relief and rehabilitation health. Since the 1960s, we have worked with health care professionals and patients to design and develop pain management and rehabilitative devices that are effective and deliver on promised results. Through extensive research and clinical trials, we are committed to developing medical innovations for muscle disorders, incontinence, post-stroke rehabilitation, pain management and more. Our easy to use, clinically proven products help patients worldwide embrace life to the fullest. Scan to view tutorial videos of the exercises contained in this brochure. For more information about the Neurotech Kneehab® XP: Contact your distributor or visit us at www.neurotech.us and click the “Contact Us” tab. This device is by prescription only. ® Designed by & Manufactured for: Neurotech A Division of Bio-Medical Research Ltd. PO Box 5179 Hoboken, NJ 07030 866-453-0578 www.neurotech.us U.S. Patent Number 6,944,503 Part No: 2441-3302 Copyright © 2013 Bio-Medical Research Ltd. All rights reserved. Rev.: 1 neurotech® is a trademark of Bio-Medical Research Ltd. Issued: 8/13